Failure to Follow Enhanced Barrier Precautions and Infection Control Policies
Penalty
Summary
The facility failed to adhere to its Enhanced Barrier Precautions (EBP) and infection control policies during the care of residents with indwelling medical devices. Nurse #2 did not wear a gown while administering medications via a gastrostomy tube to a resident, despite an EBP sign being posted above the resident's bed. There was also no personal protective equipment (PPE) available in or outside the resident's room. Nurse #2 stated she did not see the EBP sign and was unaware that gown use was required for feeding tube care. The Director of Nursing (DON) confirmed that EBP signage had been moved from doors to above beds and that PPE had been relocated to storage rooms, making it less accessible to staff. Similarly, a nurse aide failed to don a gown while providing urinary catheter care to another resident, with no PPE available in or outside the room and the EBP sign placed behind the resident's bed. The nurse aide admitted to forgetting to wear a gown and typically obtained PPE from central supply before care. The DON and Administrator both acknowledged that the EBP policy required gown use for such care activities and expected staff to comply with infection control regulations. Additionally, the Wound Nurse did not follow hand hygiene or clean dressing policies while preparing and administering wound care. The nurse prepared wound supplies after sanitizing her hands but then touched unclean surfaces and handled wound care materials with ungloved hands, failing to sanitize again before proceeding. The supplies were placed on an unclean overbed table, and the nurse used her bare fingers to prepare gauze for wound cleansing. The DON and Administrator both confirmed that the Wound Nurse should have sanitized her hands and worn gloves during these steps, in accordance with facility policy.